ckroll

Excellent question, the answer to which, it appears is that none of us have policies for pets, injured or otherwise. Perhaps it is something we should all bring up and have our departments address. If memory serves, the issue or one like it was addressed here years ago. EMS is probably the right agency to get it started. Honestly, it had not occurred to me to go pet hunting on serious medical calls, but it makes perfect sense to assign the task to someone who is not involved in patient care. Dogs usually announce themselves, but birds, cats and reptiles won't. Someone who is in charge of securing the house ought to also be tasked with doing a pet check for vacant house situations and it makes sense if local EMS agencies have vet and animal control contacts. We wouldn't leave an oven on or a door wide open, it seems reasonable that an animal not be left to die. As for injured pets, I do not know of anyone who has a policy as it is a rare occurrence. I've been on fire scenes where we treated pets successfully for smoke inhalation and recall animal control coming for injured animals at PIAA's and transporting to the vet next to the hospital. There are a number of concerns: rescuing the person from the car with the frightened pet, securing the pet, treating it. Calling animal control is a longer term solution that does not address the emergent pet. immoblizing/packaging is key and a pillowcase works well for cats and small stuff, a blanket and or sheet properly wrapped will papoose a larger animal so that it does not injure itself or others until the preplanned help arrives. If it's my call, the animal is hurt.... and a vet is available next door to the hospital... I think I will 'assume' it is a service animal, transport it in the front seat of the ambulance with the patient and take it over to the vet. That doesn't work for serious [human] trauma as WMC might not see the necessity.... Preplanning, and that might include a sheet of plastic for the chief's car, is essential. I'll be brjinging it up at the next meeting of my AC. thanks, for thinking of it.

What's in a word? I voted for the 'change' guy, and we've got change already. He's picking really smart people for key positions. I wanted change from the current, 'no regulation for business or banking and let's see what happens' attitude. Alan Greenspan [served under republicans and democrats] had the gall to so say that the problem wasn't deregulation, but that bankers did not behave honorably...Who could have seen that coming? The current administration has screwed things up. I wanted some change from that [and maybe the occasional head on a pike in the town square to keep bankers and CEOs from trying it again.] I specifically didn't want a new president to trot out people I had never heard of who had never worked in government and turn over the government to them. Former President Clinton, for all his faults, did a masterful job on the economy and I for one am happy to see some of the people who got it done right before are back in the game. An ethics panel of Clintonites might leave me a little uneasy, but right now I'm looking for economists...preferably with advanced degrees and a record of success. Give the new administration 100 days. There will still be plenty of tie left to pick it apart.

There is a huge difference between stupidity and experience and education. A brilliant EMTB may still not have the experience or education to make a wise decision. That said, you said with permission of OLMC and that is key. If an EMTB is faced with a life threatening situation and other intervention will not be timely, [that full blown asthma attack in the middle of a blizzard], then call OLMC, get permission. The EMTB should expect they will get called to defend their decision and may take some grief for it, but a life saved is a life saved.... or you decide it wasn't asthma after all but an allergic reaction..... a smart EMTB should be able to work the sytem.

We could have it end of winter and call t a meltdown.

Please, there hasn't been a wetdown worth the name in the county in 10 years. I miss the old days when a wetdown meant something. Just like football, if you haven't played with blood in your mouth, you haven't been in the game.

Well, personal discipline, mindfulness, respect for those we share space with might just solve all our problems, or at least a large part of them. Absent that, and it does seem to be in short supply, one needs guidelines for when behavior has crossed a line. So long as there are those among us who do things "because I can and you can't stop me." then we will need rules. Do not blame rules, those who ask for them, or those who enforce them. Put it where it belongs, with people who disregard the impacts their actions will have on others. Idling a vehicle for long periods is stupid, end of story. If people do it then we need a rule that says not to. It's a finite planet with finite resources. Act responsibly and expect that others will do the same and we won't need rules. Until then...

Dr. Stamler at Duke has an interesting paper from 2002 on the chemistry of nitro and how it is converted to nitric oxide in the body. To understand or to explain nitro in a useful way in a paper, I think one needs to go into what conditions it is used for. My limited understanding of NTG's by product, nitric oxide, is that it dilates blood vessels, both arteries and veins. Dilation of the coronary arteries feeding the heart, is the effect that makes it useful for treating angina. That said, I believe that while it relieves symptoms, research has not shown it to improve overall outcome for the patient. The more profound effect of nitrates is to dilate veins. This is the effect one is looking for in the treatment of CHF/pulmonary edema. At one time, I had the incorrect notion that nitro was useful/dangerous because it dropped BP. While true, it is a too simple a way to think about it. Nitro, by dilating veins, is increasing the spacial volume of the venous system. This reduces how much blood is returned to the heart a.k.a. preload. This is why it is problematic for right sided AMI. If the right side of the heart is already having a hard time getting enough blood moved into the lungs to move on to the left side of the heart, then reducing how much blood the right side has to pump in the first place can be problematic. My first experience with nitro was a few minutes into my first shift as a medic. I told the person orienting me that I had not done many 12 leads in the field, so we did them on everyone. The first patient was an elderly gentleman who had the flu. He was weak, had passed out, felt achy, threw up. And the 12 lead had honking depressions in II, III, AVF, just classic right side MI. As we were only a few minutes out from the ED, and the patient did not report chest pain [he described tightness in his shoulders] I did skills but skipped the nitro, which the cardiologist immediately ordered.... and before I even had time to feel like an idiot for not giving it..., he was calling for a crash cart. The patient did just fine, but he dropped like a rock for a minute or two. There are something like 6 different etiologies for CHF depending on what the problem is that is causing fluid to move out of the circulatory system and into the alveoli, so all CHF may not respond in the same way to nitro. In addition, arterial pressures on the pulmonary side can be much different from those on the systemic side. I don't know if the effect of nitro for relieving symptoms of CHF is due to lesser blood volume inbound to the lungs or to larger spatial volume on the pulmonary outbound side.... or maybe something else entirely. I have heard it suggested, and it sounds reasonable, that not only does high pulmonary pressure cause fluid to move into alveoli, but also that lower blood pressure actually helps the heart beat more efficiently and that is what relieves the CHF. I had a call reviewed where the patient had classic, moderate, CHF, and I had given lasix, but as his BP was 130/80, I had held off on nitro on the assumption that his pressure was not the problem and I was unsure if dropping his pressure was useful. In the resulting discussion, compelling cases were made by learned people on both sides for letting the ED give the nitro in that situation as they can do it as an IV drip which is more effective, and for giving nitro in the field because it can improve the efficiency of the heart independent of the pressure. I was won over to the position that nitro in the field in that situation was the better choice. . In any event, nitro is used with companion drugs, either with blood thinners for MI or diuretics for CHF, so it should not be considered alone. There is lots of good literature out there. Let us know what you find and good luck with your paper.

Indeed. I was trying to visualize what this left wing security force would be tasked with. I'm guessing a team in tie dyed camo's pushing in the door to see if you're separating recyclables, washing with organic soap, spending quality time with your gold fish and teaching your kids about evolution. Gotta tell folks, liberals just aren't that dangerous. Just a wild guess here, but Vista, Peace Corps? Asking 18 year olds to give a year to their country in service doesn't sound like a bad idea. New Orleans and Galveston could use a little security. Remember, not all 'security' comes at the end of a gun barrel.

That's an interesting case that deserves a thread all its own. Why don't you post it and see what responses it gets. It goes without saying you're an excellent medic of whose judgment I have the greatest regard. While protocols are intended to be applied with good clinical judgment, my reading of them is that we are not given the flexibility to go beyond scope of practice. That said, a good medic can still make the case for it to OLMC, and I think we agree, has to before doing something like that. In point of fact, most OLMC is by and large unaware of what paramedic protocols say. As a 6 year medic, I would be very circumspect about going that far over the line. Points to consider are how proficient the medic and how adventurous the Service Medical Director, and nature of injury. Given your situation with a medical emergency, that is quite different than perhaps a new medic with a commercial agency working a trauma. All that said, it must happen all the time that people are anxious about medevac. In hospital is a whole different ball of wax than in the field. How often do flight medics/nurses sedate for anxiety in the field? Do they do it under the flight medic's standing orders or is it a nurse who has the permission from their medical control?

Interesting idea. Not to be overly pedantic, but it depends on what definition of ethical you're using. I wouldn't think administration of sedation is morally questionable, as it is the compassionate choice for the patient. That said, if by ethical you mean meeting professional standards, then paramedics have no authority to administer benzo's for relief of anxiety. In addition, medical control physicians do not have the authority to ask/demand that we give benzo's for relief of anxiety as it is way beyond OUR scope of practice. That said, morphine for pain relief is still on the table and in the draft for WREMAC it is above the medical control line. "If it is truly warranted" is a good consideration. If a person is alert and oriented, and situationally aware to the point where they have the emotional ballast to be anxious over a transport decision, then that person may be stable enough that air transport to level 1 trauma vs ground transport is unwarranted. If they have altered mental status, I wouldn't consider sedating at all. If I were faced with a person who could tell me that they would absolutely, positively flip out going in a helicopter, and I took 5 minutes to try to talk them in, and then took 3 minutes to call medical control and have them talk to the patient and then took 5 minutes to give the benzo and wait for effect only to find out that they needed more..... well, I'd be at the medical center by the time I got them loaded in the helicopter and now I'm delivering a foggy patient to a trauma center and the surgeons have no idea if the fog is drug induced or secondary to injury. In addition, a person who is spooky about the helicopter is an unknown quantity. How much sedation does it take? What if they are minimally sedated to get them in and comfortable, some event happens mid flight and they have a panic attack anyway? What defines truly warranted?

I'm with those who advocate less is more. Even the AEMT written... and practical..... is half BLS. EMT-B and AEMT ought to focus on assessment and history. Many 'emergencies' can be adequately addressed in the field with oxygen and patient positioning. I had the pleasure of working with a Yorktown BLS crew recently. By the time I got on scene from out of district, the patient was packaged, in the ambulance, a full history had been taken and the 'not well' patient had been evaluated for stroke, ruled out, and the EMT was anxious for me to test blood glucose as he had narrowed his impression to low blood sugar, which it was. Solid, professional basic skills can add as much to level and timeliness of care as ALS. BLS and ALS alike need to respect the importance of solid basic skills. Good basic care is a craft which we all know when we see and work with it. I'd like EMT-B's to focus on /add pride, thoroughness and confidence.

Stress tests and physical performance evaluation absolutely should be as important as having adequate turnouts. We are part of a team. Performance is not just a matter of personal health, but also has direct impact on the safety of the people with which one works. I'm not sure that a standard cardiac stress test is the best measure for firefighting. Simple and cheap would be to ask members to run a distance, climb stairs with gear and measure how fast the individuals vital signs come back to baseline, much like the standards now for rehab. A person who can run a reasonable distance, carry a reasonable load and then have a heart rate and blood pressure that return to baseline in a reasonable time are fit for interior firefighting. If he or she can't, then that person needs to be driving, pumping or directing traffic. I think knowing that there will be annual evaluations might encourage people to keep in shape or get in shape. There is a culture of accepted obesity within the volunteer service that hurts the FD, the community, and the members.

In a dispatch from Possum County.... all names have been changed to protect the guilty.....The new ALS contract in Possum County got off to a rocky start when the new fly cars unintentionally came equipped with heated leather seats and a really awesome sound system. The first sign of trouble came when a fly car did not return to station for shift change and the medic did not answer her phone. Fears of foul play proved unfounded when the vehicle locator showed was it parked behind the station where authorities found the vehicle, medic inside, fully reclined on heated leather with Led Zeppelin playing on the radio way too loud. At first the medic, Margaret Snakely, appeared unresponsive but in fact was alert, combative and refused to relinquish the vehicle. A critical incident team was deployed to the scene as was her husband and dog, to no avail. She refused to leave the vehicle. The situation was resolved by a quick thinking dispatcher who sent the medic to a ficticous call for a child choking. When the medic exited the vehicle to render care, they got the keys. A Sheriff's Officer suffered minor burns when he contacted the medic's backside."That Snakely is one hot medic" he said. When asked to comment on the incident, management said that events were totally unanticipated but part of any new contract. They blamed the supervisor for not seeing it coming. Fellow medics were more sanguine about events. "It's a high stress job, you never know what's out there, 4 hours on heated leather and a rocking sound system... she just couldn't cope, it might have happened to any of us." The vehicles in question were due to be sent to headquarters to have the problem corrected, but at end of the next shift another vehicle went missing. This time the vehicle locator was left at the station. Responding to these new developments, management said, "Well, medics are highly intelligent and have to adapt to changing situations. We're on it. We're watching the hospitals, but apparently medics are taking patients out of region to avoid detection." "They're, crafty, but creatures of comfort," he added, "We're also watching the deli's, eventually they'll come back for food. " The county coordinator put a positive spin on things. "Medics aren't leaving the vehicles, so response times are excellent. We do have some reports of medics not wanting to get out of vehicles on scene, however." He went on to make the case for a county run system. "If we had a municipal system in place this wouldn't have happened. No way would they have gotten decent vehicles if ALS were county run." When asked what will happen next, authorities urged patience. "This is just a few rogue medics with comfort issues. Oncoming medics are as upset as we are, so self policing is our best option." At least the situation will resolve itself by spring. Management added, "It's lessons learned, we'll definitely get the air conditioning taken out before summer." If you think you've encountered a medic with hot leather seats on a call, authorities urge caution. Under no circumstances get into the fly car, push back the seat and crank the stereo. "If you're not prepared, it can blow you away." Not only that, "Heat addicted medics can be very territorial. If you get between them and their vehicles, they may become aggressive and beat the snot out of you. But not to worry, once you bleed profusely, their professional instincts kick in and they will render aid...excellent response times, too."

How does your FD manage the requirement for annual physicals? I volunteer for Department X and this year I was 16 days late getting mine because of my job. I was told by the Chief that this would be OK. Apparently he has had a change of heart. I got the physical but at the next meeting he moved me to probationary status and even though I have a department physical now, he says there is no way to return me to active status until sometime next year when I've had a second physical for 2009. It seems excessive to take a 20 year member with 1800 calls off active status for almost a year for missing the date for a physical. I am interested how other departments handle situations like this.

My assumption was the patient doesn't want the helicopter, not doesn't want the hospital. If in my heart of hearts, if I think there is an underlying injury, or condition that would benefit from ALS or vital signs are badly out of bounds, I want the patient to talk to an MD. If I think the refusal is an appropriate choice, then no, I wouldn't bother MC. Contacting MC is a requirement for ALS if there is a significant presenting problem that may benefit from it. Refusing any care and refusing a helicopter are different scenarios. A noncompliant sweaty 300lber with a pressure of 90/60 who hit a deer last night with his bike is going to talk to an MD before refusing. The point I intended to make was that if transport was necessary and going to happen, I would not waste time at scene arguing the helicopter point. I'd get moving and cancel the helicopter if the patient refused it and make sure the facility to which I was transporting was ready. The most terrifying moment of my life was dead of night at the Mahopac firehouse when a helicopter landed in difficult conditions that then deteriorated rapidly. As it lifted off, the call went out that the helicopter, still in sight, was making an emergency landing. There really wasn't room, the wind was fierce....and they opted to puddle jump to PHC instead and ground transport from there. I think the helicopter crew made excellent decisions all along. The flight was doable on lift off and then it all went to hell. They got it down and did a spectacular job. That said, I will never ask a flight crew to take away my burden of care without thinking very carefully about the need and the consequences. My husband is a fixed wing pilot so we fly regularly. I know that even the most careful preparation can still result in unforeseen weather. Watching my husband agonize over flight safety for pleasure trips, I can't even imagine the pressure to make the call to fly in seconds. My sense is that helicopter transport has to have some tangible benefit before I'd ask a crew to risk their lives.

I transport to HVHC, Putnam, Phelps and WMC. For trauma, the choice is obvious. WMC is far and away the best prepared to handle trauma and if that is your addiction, go there. Both Phelps and WMC have close to 0 time to patient contact and seldom go on diversion, that said, txp to WMC for me means a patient is in distress so my experience may be skewed. I've never taken serious trauma to Phelps. HVHC has the advantage of having been an excellent level 2 several years ago, so the staff is prepared handle it and the times I've needed to use HVHC for more serious trauma they've been first rate. Putnam Hospital won't handle any trauma at all and actively presses EMS to go to Danbury with routine injuries. That said, with Danbury just to the East, much better care is just one state away, so the may have a point. Why not put Danbury on your list if trauma is your interest?

Apparently the opening to the marine corps anthem will work as well. I did CPR on a nun in Barnes and Noble with an animated snowman singing "Have a holly, jolly Christmas." Can't recommend it.

"If you want to consider someone who meets trauma criteria who may be c/a/ox3, I would say a motorcycle accident patient with some road rash and bilateral femur fractures from an up and over collision. Now granted, we don't know if there are more injuries, but if those ended up being the extent of his injuries, he could very well be alert and oriented. He is also someone who will not be treated in a local hospital, most wont even treat simple femur fractures these days. While he may be stable for ground transport to a local trauma center, I wouldn't want to be the one debating an hour transport from upper Sullivan County versus a medevac." Fascinating, but I can hardly believe we are having this discussion. First, if a patient says no to anything, then the answer is NO. It ends there. The next consideration is not documentation of the refusal, but getting the patient to the nearest appropriate facility. Calling medical control, arguing, documentation all take time and if time is critical, get moving by ground, call for an air intercept if the patient deteriorates to the point where they can no longer make an informed decision. Second, the assumption seems to be that the need for surgery has a helicopter ride as a prerequisite. It does not. In large part, air transport takes as long as ground transport and it is harder to monitor and work on a patient enroute. Unless there is a need for RSI, the air transport has limited value added. Third, if a frightened patient is being sedated solely for the purpose of putting them in a helicopter, that is so far beyond protocols as to approach criminality. Like air transport, sedation is high risk and should be used ONLY when needed and for its intended purpose. Fourth, NYS BLS protocols spell out transport decisions for us. 2. If mechanism of injury and/or physical findings do indicate major trauma: a. Transport the patient to the nearest designated Regional or Area Trauma Center if the total time elapsed between the estimated time of injury and the estimated time of arrival at the Trauma Center is less than one hour (see Appendices for a list of the New York State Designated Trauma Centers); or b. Transport the patient to the nearest hospital emergency department if: (1) The patient is in cardiac arrest; or (2) The patient has an unmanageable airway; or (3) An on-line medical control physician so directs. (4) If total time elapsed between estimated time of injury and estimated time of arrival to the trauma center is more than one hour or if transport time from the scene to the trauma center is more than 30 minutes , contact medical control. If faced with this situation, I would think hard about whether or not air transport was the best decision in the first place. [ And in Putnam/Westchester it is hard to justify air transport]. If air transport is indicated, I would make a concerted effort on the way to a landing zone to convince the patient. If the patient refuses, keep rolling to a hospital, stabilize patient and then and only then start making calls to MC about options.

Thanks for the dialogue. If there is much more to the story than was posted, then my chief owes me an explanation. As the sidebar lists me as a volunteer and I live in Putnam Valley the department should be obvious, redaction or no. Yes, I am unhappy, but the reason for the post was curiosity pure and simple. I wanted to poll departments for their policies. If all departments behave in this fashion, then maybe it is what it is. If my department is at the end of the spectrum, then perhaps this is an opportunity to look at changing policy. Department policy should not fall to the level of 'dirty laundry' and if it does, then my observation is that that policy needs revision. .

To use a helicopter or not is a different decision than whether or not to go to a trauma center. If one reads the guidelines for using helicopters, most of Westchester and Putnam should be using ground transport to the medical center. My experience has been that landing, evaluating and loading a patient is more or less equivalent to driving it. Several years ago Putnam Valley responded to gunshot wounds. As fate would have it, I was due at Valhalla to have bloods drawn for a Lyme research study for which I am a guinea pig, so I could not go on the call. 10 minutes after the call was dispatched, I headed down the Taconic at highway speed, listening to the call back home. It was beautifully run with no down time. As I was parking my car at Munger pavillion, I stopped to watch the helicopter land at the WMC ER. If one does not get caught up in the pageantry of the moment, the firetrucks, the lights, the thrum of the rotors, the cloud of dust, awed motorists picking sand out of their teeth.... Once a patient is loaded into an ambulance, if rolling to the med center takes 30 minutes or less, and getting to a landing zone, transferring the patient and getting the bird lifted off takes 20 minutes...and it almost always does... and flight time is 10 minutes, then transport is a wash and the helicopter is expensive and not without danger. For me to use a helicopter, there has to be an airway issue or need for extended transport, say to Jacobi for a venomous snakebite. An argument can also be made that better prep for surgery can be accomplished by a good medic and crew during ground transport to a trauma center. If it's an MCI and it's a resource issue, then the helicopter may be valuable for resources, not necessarily speed of transport. That said, every situation is different and if EMS thinks it's the right thing to do, it is easier to explain why you used it than why you didn't.

When my parents sent me off to college they wanted me to have the best technology money could buy.... a K&E log log duplex slide rule.

Nice website but.... WE WANT A CALENDAR.

Providing [ meaningful - fair - equal - affordable - high quality -insert favorite adjective here ] EMS coverage for Putnam is complicated because Power, Money. Responsibility, Want/Need... the components that drive the equation... are all in different hands. The power to make the decision lies with PCBES, the money to pay for it comes from the County Legislature, the responsibility for providing EMS service lies with each Town [home rule] and it is the residents that want/need the service....and who ultimately ARE the ones paying for it. You wouldn't buy a house or a car this way. I'm not sure you could. The towns need to take responsibility for EMS or have it forced onto them. So long as the mutual aid system is applied as de facto welfare... if the town won't do the job, the county will do it for them,.... then the towns have no motivation whatsoever to solve the problem. Mutual Aid needs to be managed, not as the never ending hand out, but like a line of credit. Mutual Aid agreements should be made with towns [not the agencies], who have both responsibility and the monetary resources to provide service. The towns need to agree that mutual aid is not a right, but an obligation that needs to be paid back. If a town needs to use more mutual aid than it can provide into the system, then there needs to be quarterly review of response by the county/mutual aid consortium. If a town is not paying into the mutual aid system with service, then it needs to make a monetary contribution or it needs to hire someone to provide service. The role of the county should be to oversee the mutual aid system, set rules for membership and contract for reasonably priced service so that towns that need to pay can get competitive rates. Simply put, a town agrees that it will not use more resources in a year than it puts in. It also agrees in advance that if it does, it will pay a fee for those services or it will hire someone to provide these services. If a town does not like the rules, it does not have to participate in the mutual aid plan. Consider Putnam EMS mutual aid like a community garden. There are seven families working in the garden. Everyone needs to eat. Some weeks a family has time to weed and some weeks it doesn't. If one family continually comes to the garden and takes vegetables but does not pay for seeds, or bring water or weed, then the group would tell the family not to pick vegetables or to pay for them or hire someone to do their share of the work. If the family protests that it needs to eat, the group will remind them that we all need to eat and we all need to contribute. If the county steps in and buys the family pizza every week, it does help the other families who tend the garden, but then they might like pizza, too. And if in the end, the other families get the bill for the pizza, they might reasonably argue that the county is not only NOT solving the problem, it's making it worse by appearing to solve the problem but encouraging the family to continue to take handouts. A better solution would be for the county to set rules for using the garden, to go to the family when they fall behind and tell them to pay for veggies, help in the garden or to hire the nice boys down the street who will weed for you if you don't have the time. That's my idea for where the county management ought to be putting its efforts.

The horse is not dead, merely resting... it could be an arduous fall campaign. Life is not fair, and those who seek it are bound for disappointment. That said....One can reasonably ask that if not fair, that decisions should be just and that managers do the best with what they have. In this respect West Putnam has been sold short by decision makers who do neither. One can hope that if prospective vendors and management follow this site.... that better decisions might be made with resources at hand that might even..horrors...be money makers as well. Putnam is complicated by population densities and topography. What is driving decisions at present is the transition from volunteer to paid service. East Putnam has the population density to break even/be profitable. West Putnam is low density with abysmal terrain. Expecting fair/equal coverage ignores the monetary and geographic reality that West Putnam is and will always be a money loser with extended response times. For-Profit agencies will, and should, be reluctant to take it on. I hope that the upcoming contract will be for 2 BLS ambulances and 4 ALS flycars. Taking the longer view, if East Putnam solves its problems without tying up or displacing Medic 2, then the West side comes out ahead. If a BLS ambulance were stationed at Putnam Plaza and a second BLS ambulance were stationed at Mahopac Falls, then the Falls unit could backfill the Plaza unit as needed, but it could also backfill the West side and service the Taconic Parkway. I believe it would be a money maker and if it moved on initial dispatch, it could be in appropriate position to respond if any of the West side agencies failed to cover. Six units, each in different locations can give most of Putnam coverage in a reasonable time, and yes, West Putnam should have access to BLS assist if their volunteer agencies fail to cover. It might not be there in 10 minutes, but second choice could be a paid service that was in motion from time of dispatch. Maybe not ideal, maybe not fair, but it would work and might just make money......

What to wear is a complicated issue. I'd like to point out that many times its IPE [impersonal Protective Equipment] not PPE. My fire gear is fitted and I wear it always. [30 coat, 28 pants, 4 1/2 boots] When responding as EMS, however, I rely on a generic coat and helmet. I have yet to put on a coat from the back seat where my finger tips extended beyond the cuffs. That's not protection, that's useless. Showing up at a scene looking like a kid going out in a parent's turnouts for halloween is silly. And shared gear is not all that clean. A filthy jacket and leather gloves does not comfort a patient. If they are needed, they are needed, but if they aren't, excessive safety for incidents may be overkill, and worse if gear doesn't fit. Each incident needs intelligent evaluation for hazards and those who refuse to wear proper protection are idiots. That said, the majority of incidents can be safely managed with EMS wearing goggles and sharing the cheesy yellow blanket with the patient. Does the EMS worker need more protection than will be offered to the patient?